Reader's Watchdog: VA policy on eyedrops - prudent or wasteful?

Jan. 29, 2013
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Dr. Robert Brown’s concern might seem a droplet when you consider the deep bucket of federal government spending.

But as members of Congress bump heads over our $16.4 trillion national debt and trade barbs on government waste, an eye surgeon’s complaints about a questionable Department of Veterans Affairs policy could seem right up there with $800 toilet seats.

Brown’s beef: Every time a patient comes to the eye clinic at the VA health care center in Des Moines, nurses and technicians are required to use only new bottles of drops — for numbing, dilating, treating glaucoma, you name it.

The workers, he said, must provide proof at the end of each day that the bottles are thrown away after a single use, even though some bottles could treat 60 to 80 more patients. With 9,000 eye patients at the VA in Iowa each year, how much is this policy costing taxpayers?

Others in the eye clinic find the policy wasteful, too, and have complained to Mary Beth Gross, the VA’s pharmacy chief in Des Moines. But Brown said they’ve been told there’s nothing they can do.

“You do this a while, and it becomes obvious that this is a terrible example of government waste and so blatant,” Brown said.

Brown is in a position to know: He has been a part-time surgeon in opthalmology for five years at the VA’s Central Iowa Health Care System, serving hundreds of patients.

Brown, who retired a few years ago from private practice, said he knows the single-dose policy is there to prevent cross-contamination from patient to patient. But drops are applied by nurses and technicians who are trained on safe usage, and all drops contain preservatives designed to kill bacteria and prevent cross-infection, he said.

This, of course, made me wonder how others in the field handle their drops, so I called some eye centers around town.

Maybe, Ingram said, he could see throwing out drops after a set period of time, but he thought that probably wouldn’t happen at a busy place like the VA, with so many patients.

A more cost-efficient policy, he said, is what most eye professionals in the field are taught to do: Throw the bottle out only if you accidentally touch the eye.

How much do these drops cost?

A sales brochure from Sigma Pharmaceuticals (provided by my own eye doctor at Vogue Vision) gives you some idea. A bottle of artificial tears from Alcon costs $4.95. But a 2.5 milliliter bottle of Lumigan, an anti-glaucoma agent, runs $119.50.

A 5 ml bottle of the common dilating agent Mydfrin costs $6.50. If the techs used one bottle for each patient visit here in Des Moines, the annual cost would be $58,500.

On the other hand, contamination can be deadly.

Consider the meningitis outbreak last October tied to a Massachusetts pharmacy. It caused the deaths of at least 233 people.

After a federal raid at the New England Compounding Center — which shipped all sorts of drugs to patients, including eyedrops — federal officials urged doctors to check not only people who had received injections of steroids, but all sorts of medical products. Of course, officials also told the media that exposure by the skin or eyes was unlikely to affect otherwise healthy people.

The Food and Drug Administration has been considering whether special packaging might be necessary for post-op patients, because serious infections can cause blindness.

Surgeons already tell patients to use separate containers for each eye after surgery for cataracts, for example, because they are at greater risk for infection and natural protective barriers such as the cornea have been breached.

Still, the FDA also has been warned that a practice of throwing away all eye medications after each use could wipe out some hospitals’ entire drug budgets.

I wanted to see how many kinds of drops Brown was talking about, so last week I stopped by the VA regional office at 3600 36th St.

Folks there said they probably use 15 to 20 different kinds of drops that vary widely in cost.

Afterward, I posed several questions to Bart Quick, the Des Moines VA’s acting public affairs chief.

Quick said he could not answer all of the questions, but he did learn that the decision to throw away containers of drops after just one use was made locally. It stemmed from published research finding contamination rates as high as 11.7 percent among eye patients in primary care settings.

The local policy was put in place in 2007 by the Central Iowa VA’s pharmacy and thereapeutics committee, and it actually applies to any multiple-dose pharmaceutical used at the Des Moines VA facility.

Quick said eyedrops do follow admitted patients for surgery, but they are thrown away when used on an outpatient basis.

An employee complained about a year ago to the federal Office of the Inspector General, which ultimately decided the policy was up to the discretion of the director.

When asked about commercial businesses that do things differently, Quick said: “It’s not uncommon for the VA to set a higher standard.”

He cited as examples the practice of using bar coding and wristbands to identify patients at a time when other hospitals didn’t.

Quick said the Des Moines VA does try to use single-use vials whenever possible, but I said others in the field told me those weren’t yet available in the United States for eyedrops.

I asked him to share with me the total that the VA here spends annually on each of the eyedrops, as well as the costs of other medications subject to the single-use rule.

On Monday, he said the VA considers my questions a request under the federal Freedom of Information Act — but he assured me they would be answered.

Stay tuned.

Lee Rood’s Reader’s Watchdog column helps Iowans get answers and accountability from public officials, the justice system, businesses and nonprofits. Contact her at lrood@dmreg.com or by calling 515-284-8549. Read past reports at DesMoinesRegister.com/ReadersWatchdog.